Facts About Liver Failure and Liver Transplantation
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Facts About Liver Failure and Liver Transplantation

The cause of liver injury can be grouped into four categories. Hepatic fibrosis and remodeling (cirrhosis) reduce the flow of blood through the low pressure portal venous system.

The cause of liver injury can be grouped into four categories:

Loss of hepatic synthetic function: Direct injury to the hepatocyte resulting in decreased synthetic function primarily manifest by hypoalbuminemia, hyperbilirubinemia, and hypoprothrombinemia.

Portal hypertension: Hepatic fibrosis and remodeling (cirrhosis) reduce the flow of blood through the low pressure portal venous system. This results in the development of venous collaterals which bypass the liver; these collaterals occur at the sites of portosystemic anastomosis and cause gastroesophageal and rectal varices and prominent veins in the abdominal wall. Portal hypertension also results in the accumulation of fluid in the abdomen (ascites) and hypersplenism (splenomegaly and pancytopenia).

  • Treatment of variceal bleeding is a medical emergency and requires resuscitation with intravenous fluids and blood. Pharmacotherapy with intravenous octreotide reduces the portal pressure. This is usually followed by endoscopic therapy with band ligation or sclerosing injection of varices. The use of noncardioselective B-blockers such as propranolol and nadolol significantly reduce the risk of subsequent bleeds.
  • B-Blockers also have an important role in the prophylaxis of variceal bleeding—preventing the primary bleeding episode in individuals known to have cirrhosis and large gastroesophageal varices. Refractory bleeding may be controlled by transjugular intrahepatic portosystemic shunt (TIPS).
  • Ascites is generally managed with salt restriction (<2g/day) and diuretics (spironolactone and furosemide). Refractory ascites may be controlled by TIPS.

Hepatic encephalopathy: This ranges in severity from mild confusion and difficulty sleeping to unresponsive coma. Hepatic encephalopathy is associated with hyperammonemia. In association with chronic liver disease, encephalopathy is purely functional and reversible. However, when encephalopathy arises in the setting of acute liver failure it may be secondary to cerebral edema, which if severe may be complicated by uncal herniation and death.

  • Hepatic encephalopathy is treated with lactulose, a nonabsorbed sugar that causes osmotic diarrhea and acidifies the lumen of the colon, thus reducing the absorption of ammonia.
  • Nonabsorbable antibiotics also decrease the bacterial load in the colon and hence the production of ammonia.

Vascular changes including systemic vasodilatation and a hyperdynamic circulation may precipitate hepatopulmonary syndrome and hepatorenal syndrome, both serious and potentially life threatening complications of cirrhosis that reverse promptly after liver transplantation.

Liver transplantation is now commonly performed for patients with end-stage liver disease (more than 5000 cases each year in the United States). Organ allocation for adults in the United States is based on the MELD system (Model for End-Stage Liver Disease). The MELD score is calculated based on serum bilirubin, prothrombin time, and serum creatinine levels. Organs are allocated first to those individuals with the highest MELD scores.

  • Liver transplantation is associated with 5-year survival rates of 80% to 85%. Liver conditions with the best survival after liver transplantation are primary sclerosing cholangitis (PSC), primary biliary cirrhosis (PBC), autoimmune hepatitis, and hepatitis B; liver tumors tend to have the worst prognosis.
  • Hepatitis C, the most common indication for liver transplantation is associated with universal recurrence of hepatitis C virus (HCV) infection and some graft loss caused by recurrent cirrhosis beginning approximately 5 years after a successful transplant.
  • The use of long-term immunosuppressive therapy is critical for preventing rejection of the liver graft. The mainstays of immunosuppressive therapy are cyclosporine and tacrolimus.
  • Corticosteroids are used early in the posttransplant period and to treat episodes of rejection.
  • Other more recent agents used to immunosuppress the liver transpant recipient include mycophenolate mofetil and rapamycin.

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Comments (2)

Health is wealth...Thanks for sharing!

Thanks for sharing your expert knowledge on this subject. Well done!